Abstract

Cochrane Collaboration researchers conducted a review of the effects of
pre-referral rectal artesunate for people with suspected severe malaria,
living in rural areas without healthcare services. After searching for
all relevant trials up to May 2014 they included only one randomized
controlled trial. This trial was conducted at various sites across
Ghana, Tanzania and Bangladesh, and enrolled 17,826 children and adults.

Severe malaria is a serious medical condition caused by infection with
the Plasmodium parasite which typically causes vomiting, anaemia,
fitting, coma, and death. It is treated by giving injections of
antimalarial drugs, which need to be started as quickly as possible to
reduce the risk of death and brain damage. In some rural areas where
malaria is common, people have to travel for several hours to reach
healthcare clinics and hospitals, and many die on the way. In these
settings, people without formal healthcare education could be trained to
give artesunate rectally to start treating malaria before transporting
the patient to hospital.

What the research says:

Only one trial evaluated rectal artesunate as pre-referral treatment. In
the African sites only, children aged 6 to 72 months were included in
the trial; while in the Asian trial site, older children and adults were
included.

Young children in the African and Asian trial sites (aged 6 to 72
months) had fewer deaths with rectal artesunate than with placebo
(moderate quality evidence). However, in Asia among older children and
adults, there were more deaths in those that received rectal artesunate
(low quality evidence).

In the African sites, 56% of children took longer than six hours to
reach hospital whereas over 90% of people in the Asian site reached
hospital within six hours.

The unexpected finding of more deaths with rectal artesunate in older
children and adults should be taken into account when forming national
and local policies about pre-referral treatment.